Charles Rosenberg back in 1989 discussing the AIDS epidemic came up with 3 phases of an epidemic. The earliest signs are subtle. Whether influenced by a desire for self reassurance or a need to protect economic interests, people ignore clues that something is wrong until the acceleration of illness and deaths forces a reluctant acknowledgement.
This recognition launches the second phase in which people demand and offer explanations both mechanical and moral. The quality of these explanations generate dramatic and disruptive reactions which are sometimes as bad as the disease itself. This is what is playing out in most of the world right now.
All epidemics will eventually resolve whether due to actions taken against them or because they run out of susceptible victims.
In any historical analyses of epidemics over the years the one common theme is how medical and public health interventions fail in their promise. The other is, you always wonder why more action was not taken and earlier.
Pandemics Will Happen. It's How You React, That Matters
Keeping all the above in mind lets talk about the current novel coronavirus experience, and more importantly, the learnings. A novel pathogen arose from China- yes! But this is not the first and last time this will happen. Was the first reaction of the authorities to deny and suppress information?- yes! Did the local government react with massive authoritarian interventions? - yes! Was this needed?
In my opinion China’s “overreaction” or to my mind aggressive reaction delayed the global spread of the disease. While the efficacy of quarantine will always be debated, what is clear is that stringent controls, bans on public gathering and other forms of isolation slowed the course of the epidemic and quite frankly reduced total deaths.
2 aspects of epidemics are distressingly familiar. The first is the “shaming” and stigmatizing of the country of origin and in fact its people in this case the Chinese. The second is the danger that healthcare providers put themselves and their families through. This can be labeled as professional hazard and most understand the risk of being in this field.
What I find inescapable is how easily governments ask these healthcare providers to go to medical war without the right equipment, tools and even protection.
What the Chinese Got Wrong
Now having access to Chinese CDC data there are some stunning findings. The fundamental truth is that health authorities will NEVER know the exact number of cases in the community because they only know about a case when a patient goes to get diagnosed. So its important to note that authorities in Wuhan only knew that they were in trouble when the symptoms started and people showed up in hospitals, clearly missing the hundreds of undiagnosed cases already brewing in the community.
So on January 21st for example, when 100 new cases were announced there were actually 1500 new cases and growing exponentially. When the authorities shut down Wuhan on January 23rd they had announced 400 new cases, but in retrospect the real number was 2500 cases. This is where I think India is at.
As soon as Wuhan was shut down the number of new cases dropped dramatically, and after peaking 2 days later, has gone down ever since. In addition, the rest of the regions response in China was coordinated by the Central government so they took immediate and drastic measures to contain the numbers.
Want to End a Pandemic? Transparency is Key
Another aspect of interest is you wonder why cases in rest of Asia haven’t exploded the same way that we have seen in Europe and now the US? Most of these ( Japan, Singapore, Hong Kong etc.) were hit by SARS in 2003 and all of them learned from it. They learnt the hard way how viral and lethal it could get, and they took steps to address it. The coordination between various arms of the government, regulatory authorities and public health has been admirable. The key differentiator to me has been the transparency and dissemination of lucid, clear and simple information to put a lid on any panic.
As we look around the globe we know one fact - Coronavirus is already there in your country, its hidden and will grow exponentially. The WHO estimates the mortality rate to be 3.4% which I think is right, however needs to be viewed from a prism that immune compromised people, with chronic disease like hypertension / diabetes, ends of the age spectrum (very old) will be uniquely susceptible and have higher incidence of the disease. There is my view that weather factors, especially humidity and temperature will play a role and as summer starts in Asia, the cases and virulence will come down.
The pressure on the healthcare system is immense. Around 10% cases would need hospitalisation, 3% would need intensive care and another 0.5% would require very intensive care help- think ventilators etc. Quite simply no country has these resources available.
What needs to be done? Flatten the infection curve. Since it is already a pandemic what we can do now is minimise the impact. We need to postpone the disease which in turn will reduce cases, allow time for the healthcare system to handle the cases and lower fatality.
How to Flatten the Curve?
Social Distancing: We know that the virus can spread within 2 meters ( 6 feet) if someone coughs but otherwise falls on the ground and wont infect you. The worst infection comes through surfaces as it can survive upto 9 days on metal, ceramics and even plastic. So doorknobs, tables, elevators etc. are extremely potent vectors for transmission. Regular cleaning is the only solution. Finally by eliminating crowds and eliminating contact.
Containment: Ensuring that all cases are identified, controlled and isolated. This is what we are not doing as well in India currently. China did that well later and enabled control of this disease in a country of 1.5 billion people. This is also what most Western countries have not done at all, which has enabled proliferation of disease which is 3X more than Hubei which locked down much earlier.
Mitigation: This requires heavy and stringent social distancing which is the most painful and hardest to implement and where most governments fail.
How Worried Should We Be?
Some experts worry that almost half of the world’s population could be infected by the year end. However catastrophic epidemics that kill millions are exceedingly unusual. This has spread due to a unique combination of a smart merciless pathogen who collided with a society which provided requisite human animal contact, urban crowding, global travel and historic underspend on healthcare to create a massive deficit in public health infrastructure.
The key learnings from this as we look back later this year are - Strengthening needed of public health, sharing of real time information, mass vaccinations when available and governmental will to enforce unpopular decisions for the greater good.
The interconnected world today is like a cruise ship in the ocean. You can't hide from a viral infection as you can't get off the boat. All you can do is to follow the principles above and hope that a cure or vaccine is found while you shelter. Till then “flatten the curve” by minimising its spread.
Also Read: Explained: The 4 Stages of COVID-19
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